I spoke about foreigners and relative attitudes between them and myself. But, truth be told, one of the reasons they think they are in deepest darkest Africa when they are here is because they are!!!

We pick up the story roughly where I left it off. The initial accident claimed two lives. Then the young son has to survive a brain bleed and a neck fracture. Somehow the neourosurgeon sorts all that out. Then in ICU he gets acalculous cholecystitis and I meet him, almost in exitus. We fetch him from the pearly gates and tie him up in ICU for a while. He survives. He can walk. His maths and science still works. Miraculous!

But for a moment imagine the father, the only one not really injured in the accident. He is in a foreign country. He has just lost 50% of his family and there is a real chance his son might die or be paralysed or retarded for life. The daily ICU vigil alone must have taken a toll on him. And then things slowly start improving.

After too long away from home they are ready to leave. The son is amazingly well. He is neither paralysed nor retarded. Also he is alive which everyone sees as a positive thing. Then they have the unpleasant task of getting the bodies of the other two members of the family. What do they find? Certain body parts are missing, including one hand!!! Stolen from the dead in the morgue. You just can’t make this sort of thing up. I dare you to try.

I have spoken before about body parts stolen to be used by sangomas for so called traditional medicine, so I suppose I shouldn’t be shocked, but I was. I couldn’t help feeling for him. Over and above all the terrible things that happened to this man and his family he has to endure the bodies of his departed family being desecrated.

This story so affected me I followed it in the local papers for a while and pretty much put it together. At least some of the people were actually arrested so quite a lot of the story became public. It seems there were people working in the morgue who regularly stole body parts to sell to sangomas. They would target the bodies which were to be cremated and cut out the desired organs just before cremation. No one would be the wiser. The foreigners were targeted, it seems, because the body lay in the morgue so long while the boy recovered in hospital.

So, in conclusion, this is deepest darkest Africa and here you will truly be amongst us savages.

Recently I spoke a bit about interaction with foreigners. The impression I left would have been strained to say the least. But as with all things there must be balance.

They were tourists (aren’t they all?) when in the Kruger she developed severe abdominal pain. Her son brought her to hospital.

When they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were American and that her son, the one who brought her in, was a physician. Let me take a moment here just to mention a language difference between English and Americaneese. In South African English, a physician is a specialist in internal medicine. In American, it seems, a physician is simply a doctor. At that time I did not know this. None of us did. So when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety MD.

I mentally prepared myself for a confrontational family. Usually with non medical first worlders they question you at every turn. A physician (South African definition) traditionally is sceptical of the knife-happy surgeon. I couldn’t help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. All I could hope for was a benign abdominal cramp which would soon pass.

The patient was in pain. She associated her discomfort with some or other something she had eaten the previous day in the Kruger. But it just seemed too severe. Besides, could anything bad actually come out of the Kruger? She had none of the signs which indicated that she needed immediate surgery. But the pain really bothered me. It nibbled away at the back of my mind. Then came the x-rays. They were worrying. I was looking at a partial obstruction, but the bowel was just too distended. One more thing to quietly eat away at my mind.

Then suddenly the son appeared as if out of nowhere. He greeted me in a friendly manner. I introduced myself as the surgeon. Even after hearing who or rather what I was, he remained friendly. I remained guarded. Afterall I was under the impression I had to do with a physician (when in actual fact I later found out he was only a doctor).

I showed him the x-rays. He could see they were not good. I then went on to tell him I was worried and I felt an operation was in order. At this stage let me mention that a partial bowel obstruction does not need to be operated immediately. It can be left for the next day. But in this case there were just a few too many things eating away quietly at my mind. I had a pretty good idea what this meant. He surprised me. He said that I should do whatever I thought was needed. I did.

The operation went as I expected. I expected necrotic bowel. I resected what was needed and did all the other things that us surgeons do in these circumstances. But when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. This was no exception. We were worried about here generally and her hemodynamics and kidney function specifically. We were worried enough to send her to ICU. The gas monkey even felt the need to leave her intubated. I concurred.

After I had tucked her into bed in ICU I wondered where her son was. It was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. But I just felt I’d better check in the ward where his mother would have gone to if she hadn’t ended up in ICU. He was a colleague and besides, he might expect the worst if he found his mother in ICU intubated unexpectedly. I took a stroll to the relevant ward.

I found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. I smiled. I was starting to like them.

I greeted them warmly. I didn’t want them to expect the worst. I then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to ICU. I reassured them that she was well and we expected no further unforeseen problems. I warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. He was pretty ok with everything but I could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to ICU.

He put a strong face on it. He asked me a few questions and I did my best to reassure him on each point. Then he asked a question I was afraid I would not be able to reassure him on.

“And when we go down to ICU, will we be able to speak to the intensivist?”

“Umm…errr….that would be me.” After all, this was a peripheral town in South Africa. In fact there is no real intensivist in our entire province. Suddenly I felt sorry for these Americans. They were far from home, their mother was very sick and the best they had to look after her in ICU was a mere surgeon. There must have been at least some inkling of a misgiving in their minds. But he didn’t show it. He smiled at me and simply said;

“Ok. Well we’ll see you tomorrow morning then?” I was impressed.

The next morning I did not see them. They must have still been asleep after such a late night, I assumed. However the following few days their involvement really did leave an impression on me. It was also about this time that I realised he was not in fact a physician as I understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).

Anyway the patient did well. She had the setback of a bit of wound sepsis which, considering everything, I could live with (although I have heard that some people in America want to put it onto a never event list?????). That was soon sorted out and after not too much time she was sent on her merry way.

This case also caused me to be contacted from the States. The patient herself sent a thank-you letter as soon as she got home, as did her son. She then sent a further thank you letter a year later and the year after that.

So, if I left the impression that I have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.

Ask almost any surgeon and he will tell you your chances of surviving a catastrophe are inversely proportional to your usefulness to society. This sentiment is expressed in different ways by different surgeons but the basic message is the same. If two people come in with exactly the same injuries and one is a teacher who spends his extra time in community upliftment projects and the other is an armed robber, the armed robber will sail through treatment and be back on the streets in no time, but the teacher will slowly waste away in ICU and finally die. Unfortunately it seems to be true.

There was a super clever cardiologist friend of mine who speculated as to why this was the case. He basically divided people into two groups, those with over active immune systems and those with just the basic immune system. The first group would tend to be allergic to everything and be over protected by their mothers. They would tend to grow up in a protected environment devoting their time to inside activities (safe from the dangers of the outside world, including grass and pollen and dog hairs and the like) reading and bettering themselves. The latter group would be immunologically free to run around like wild things doing whatever they liked.

He then extrapolated this to the likelihood that the first group possibly had a higher chance of developing SIRS (systemic inflammatory response syndrome) after major trauma and it was in fact their own immunity’s overreaction that finally brought them down. Amazingly enough this theory is based on logical scientific thought.

Like all surgeons I too tend to think that the good guy will probably die and the bad guy will survive. I have seen it too often. But unlike my boffin cardiology friend I think it is just some sort of evil cosmic reverse karma that is out to destroy all good people in this world. This makes much more sense to me than actually trying to understand immunology. And that is why I try to do at least one bad thing a day so that if something does befall me I at least have a chance of surviving. But there are always limits.

A few years ago our hospital organised a weekend away for all the doctors and their families. It was at a really nice lodge here in the Lowveld and truth be told, it was great. The days were pretty much spent lounging around the pool. That is of course if you didn’t play golf. I don’t play golf.

Anyway, there I was producing vitamin D for all I was worth when I glanced over at the pool. One of the other doctors had a small boy of about 4 years old that had been running around all day like a mad thing. But at that moment, as I looked at him leaning over the edge of the pool he toppled in. I was about 10 meters away so I first looked to see who was closer that would respond. No one moved. No one had seen him fall in except me.

Then everything went into slow motion. I could see that he could clearly not swim. His eyes were wide open as his arms an legs flayed about helplessly not bringing his head any closer to the surface. He was clearly in trouble. Then a strange thought went through my mind based on my above mentioned philosophy.

“If I leave him, that is bad enough that I will probably live forever.”

I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.

It was the time of the taxi wars. Now taxis in our country are nothing like you might be thinking. They are fleets of mini-buses, quite often owned by people of questionable legal character. Occasionally rival groups try to take each other out (I mentioned this before here). But roughly at the turn of the millennium there was outright war. When the war came to Pretoria we saw quite a few of the victims, but neurosurgery got the most. A friend of mine was rotating through neurosurgery and this story came from him.

There had been a contact between two different taxi organisations. The casualties were streaming in. The neurosurgeon and my friend, his trusty lackey, were overworked and I think it had affected their sense of humour. So while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. When the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. And this is what they did.

The neurosurgeon looked at each patient in turn. The first three he told them to send into casualties for his attention. But the fourth…he took one look at the fourth and exclaimed;

“Vat hom weg! hierdie een is gefok!*”

My colleague laughed the next day when the newspapers reported: “On arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty.” Fortunately they did not quote him verbatim.

Sometimes before you are even called the sh!t has already hit the fan. The mopping up is not fun.

I was on call. As usual I was hanging around in the radiology suite (I spend a lot of my free time there sharpening up my CT scan reading skills. The radiologists even think I’m a frustrated radiologist, poor fools). The urologist phoned me. He had a nervous laugh. Most types of laughs of urologists I quite enjoy. But the nervous laugh I do not. He then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. I quickly called the scan up on the monitor and sure enough there it was. The patient was mine.

There was an 8cm aneurysm. But just anterior to this there were signs of recent retroperitoneal bleeding. This was not good. The guy was just one step away from a fatal rupture. I phoned my vascular colleague in Pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. Then another call came through.

“Doctor, the urologist says I must call you about his patient. He says it is now your patient. Something has happened.”

I knew I needed to run.

“I’m on my way!”

As I rushed through the ward I saw what must have been the family. They were all looking anxious and some had tears in their eyes. I rushed on. I needed to focus.

In the patient’s room it looked like well orchestrated chaos. Lying on the floor was a massive man who was as pale as a sheet. The casualty officer was intubating. A sister was doing CPR. The urologist looked up.

“Glad to see you! well then I am no longer needed. See you around.” And with that he walked out. Someone was trying to place a drip with little to no success. A large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. I needed to take control. Only thing is I had seen the scan and I knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).

I told the nurse to stop CPR long enough for me to check for signs of life. There were none. She continued. I then did some basic tests to gauge brain stem function. There was no detectable brain stem function. I called it right there.

After a dramatic unsuccessful resus there is usually an eery silence in the room. Maybe it is a sort of respect for the departed or maybe it has to do with confronting one’s own mortality. I think it has a lot to do with thinking who is going to say what to the family.

“Are you going to speak to the family?” I asked the casualty doctor. I had to try.

“No! you are!”

“Great!” I thought. “I walk in on the closing act and I’m left with the hot potato.”

I took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. Then I went quiet. I needed to focus.

The family had been taken into the sisters’ tea room. They then sent me in. The mopping up had begun.

I have spoken before about breaking bad news. Fact is, it is never easy and I’m not sure there is any easy way to do it. I try not to leave the family in the dark too long. Once they know I try to be as supportive as possible and to answer their questions as best as can. Usually I am struck by the human tragedy and I allow it to affect me as it should. Sometimes when I have been overcome by the relentless nature of my work I must stand back and observe. This was one of those times.

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